Safety Recommendation A-15-024

Our previous letter restated our findings from the SpaceShipTwo accident investigation that were the basis for this recommendation. In our investigation, we found that AST inspectors had limited time in which to understand a permittee’s or licensee’s training, procedures, and operations before conducting the inspections specified in the safety inspection plan (SIP). Because the AST inspectors for the accident flight did not have any significant experience with Scaled, they lacked ongoing knowledge of Scaled’s operations and procedures.

Consequently, they overlooked the simulator software change and the inconsistencies between the flight test data card and SpaceShipTwo’s pilot operating handbook. In addition, although the SIPs were designed to ensure compliance with federal regulations and the representations made in the experimental permit application, none of the AST inspectors for the accident flight, or for the two preceding test flights, verified whether Scaled was performing the mitigations involving the simulator and chase planes that were identified in the waiver of two federal regulations issued by AST.

On January 11, 2016, we replied that, although you believed that you had effectively addressed this recommendation, the system that you described in your October 30, 2015, letter was similar to the one that did not prevent the SpaceShipTwo accident. Therefore, we concluded that you had not addressed the recommendation. Before we closed Safety Recommendation A-15-24, we asked what actions you had taken to address the problems that we found in our investigation.

In your most recent letter, you described the actions completed in response to Safety Recommendation A-15-22 that improved the linkage between your license and permit evaluation outcomes and the safety inspection procedures in P-008. You believe that the procedures used with the revised P-008 ensure that information related to waivers and processes is incorporated into SIPs. In addition to the procedural steps described in P-008 and in your previous letter, you continue to strengthen your inspector workforce and align it with the areas of highest activity. You have taken these steps as AST’s workload continues to significantly increase.

You indicated that during the past year, the number of unique applicants seeking FAA authorization has grown by roughly one-third, and you are working projects with approximately 45–50 unique companies at any given time. In 2016, you added four additional safety inspectors to the previous staff of 14 credentialed inspectors.

The improvements that you have made to P-008 address Safety Recommendation A 15 22, but do not address Safety Recommendation A 15 24. Increasing the number of inspectors was needed, particularly considering the inspectors’ workload and the rate at which it is increasing. However, Safety Recommendation A-15-24 asks that there be a single inspector throughout the life of an experimental permit or launch application, and the actions you have taken are not an acceptable alternative. Because you consider your actions complete and do not plan to take any further action, Safety Recommendation A-15-24 is classified CLOSED—UNACCEPTABLE ACTION.

-From Michael P. Huerta, Administrator: In our initial response to A-15-22, we outlined improvements in the linkage between our license and permit evaluation outcomes and our safety inspection procedures (P-008) to ensure that information related to waivers and processes that are critical for public safety are fully incorporated in our safety inspection plans. As noted earlier in this letter, the FAA has completed its implementation of actions related to A-15-22.

In addition to the procedural steps discussed above and in our previous letter, the FAA continues to strengthen our inspector workforce and align them to the areas of highest activity. This is crucial as we work to keep abreast of a rapidly growing commercial space industry. For example, during the past year, the number of unique applicants seeking FAA authorization has grown roughly by one-third. The FAA is working projects with approximately 45-50 unique companies at any given time.

To further demonstrate our commitment to addressing this area of concern, in 2016, we added four additional safety inspectors to our previous staff of 14 credentialed inspectors, increasing our inspector workforce by 29 percent. One inspector has been assigned to Vandenberg Air Force Base to support west coast operations. The remaining inspectors are all assigned to our Florida field office due to the sustained growth of current (77 percent of all inspection activity) and future operations that we expect in that region of the country.

This arrangement allows each of the inspectors to gain in-depth familiarity with the specific public safety characteristics, features, and operational practices associated with the launch sites, vehicles, and the specific operators, while ensuring we meet our broader public safety mission.

We issued this recommendation because we found in the SpaceShipTwo accident investigation that AST inspectors had limited time (even with a pre-inspection meeting to prepare for a launch inspection) to understand a permittee’s or licensee’s training, procedures, and operations before conducting the inspections specified in the SIP. Because the AST inspectors for the accident flight did not have any significant experience with Scaled, they lacked ongoing knowledge of Scaled’s operations and procedures and missed the change to the simulator software and the inconsistencies between the flight test data card and the SpaceShipTwo’s pilot operating handbook.

In addition, even though the SIPs were designed to ensure compliance with federal regulations and the representations made in the experimental permit application, none of the AST inspectors for the accident flight, or for the two preceding test flights, verified whether Scaled was performing the mitigations involving the simulator and chase planes that were identified in the waiver that was issued by AST of two federal regulations.

Your letter described that, in 2012 (long before the SpaceShipTwo accident), you had initiated an approach that assigns a dedicated safety inspector (SI) to support each individual program at the inception of each license and permit application, beginning in the pre-application process phase. That same SI continues through the completion of the application evaluation in order to provide appropriate input and feedback to both the operator and the FAA evaluation team, while the SI is also learning all pertinent inspectable operational items, mitigations, and special terms and conditions associated with a specific operator’s planned activities and processes.

The SI assigned to each evaluation program incorporates all applicable inspectable items into a comprehensive SIP, which SIs other than the one assigned to the operator use to verify compliance once inspections begin for that operator. In this approach, any SI may monitor any licensed or permitted operation to verify operator compliance and ensure public safety. Thus, the SI may not be the one who is most familiar with the operation.

In your letter, you indicated that, although assigning specific SIs to each operator’s program works over the course of an extensive pre-application coordination and evaluation review, you do not believe it is either feasible or desirable in an operational environment. You described three specific concerns: (1) the size of the credentialed AST SI workforce, (2) the dynamic nature of launch operations scheduling, and (3) the central role of launch sites in the public safety aspects of commercial space flight operations. You believe that you have effectively addressed this recommendation and consider your actions complete.

-From Michael P. Huerta, Administrator: We understand the Board's intent and expectation of benefits, such as improved knowledge of individual operators and their vehicles, by aligning a dedicated SI to a specific launch operator and all of their subsequent operations. Because of these potential benefits, AST initiated an approach in 2012 to assign a dedicated SI to support each individual program at the inception of each license and permit application, beginning in the pre-application process phase.

That same SI continues engagement through the completion of the application evaluation in order to provide appropriate input and feedback to both the operator and the FAA's evaluation team, while they are also learning and capturing all pertinent inspectable operational items, mitigations, and special terms and conditions associated with a specific operator's planned activities and processes.

This approach is now institutionalized in our respective internal procedures documents: P-0 11, which governs pre-application coordination, and P-002, for license and permit application review and issuance. The SI assigned to each evaluation program incorporates all applicable inspectable items into a comprehensive safety inspection plan, which other Sis employ to verify compliance once inspections begin for that operator. We also review these safety inspection plans following the completion of each launch or reentry inspection campaign to discuss and identify lessons learned and modify the safety inspection plan where needed.

This approach allows any SI to monitor any licensed or permitted operation, verify operator compliance, and ensure public safety consistent with authorizing statutes and the CST regulations.

While assigning specific Sis to each operators' program(s) works over the course of an extensive pre-application coordination and evaluation review, the FAA does not believe it is feasible in an operational environment, nor is it necessarily desirable given the public safety aspects of space launch operations and the dynamic nature of the CST industry. Specifically, our concerns are in three primary areas: the size of the credentialed SI workforce, the dynamic nature of launch operations scheduling, and the central role of launch sites in the public safety aspects of CST operations.

AST's SI Workforce AST is a small organization (81 full time positions in FY 20 15), with only 14 credentialed SIs distributed across three field offices and headquarters. The FAA believes that we must ensure that all Sis have familiarity with a number of different launch/reentry vehicle systems and operators. Each launch/reentry system has different configurations and processes and many operators employ more than one launch vehicle system.